D Mutter (France), J Marescaux (France)

English - 25'05''

January 2013

We report the case of an obese patient (BMI of 40) presenting with a moderately secreting pheochromocytoma – Noradrenalin: 0.97micromol/L (N<05). She has a previous history of follicular thyroid cancer operated on 4 years ago, and imaging was performed in the follow-up of this cancer. Diagnosis was confirmed by serum chemistries and imaging studies: MIBG scintigraphy was positive on the right side, and a 4cm tumor was identified on CT-scan. The decision was made to perform a laparoscopic adrenalectomy.

Set-up and trocars positionIt is the case of a patient presenting with a right-sided pheochromocytoma confirmed biologically. We started the procedure by using an open access with a 30-degree angle camera, first trocar in place under direct vision. Now that the position of the camera is confirmed, we can start the procedure with the insufflation. So this woman has had a previous umbilical hernia treated, and you see that there are adhesions; they will be at the origin of a liver retraction problem.

00'55''

Dissection for exposureWe have to free these adhesions because they are between the gallbladder and the liver. We will place a second trocar. Now we see much better these little adhesions. They have to be freed. We change the position. We see that these adhesions are between the omentum, the parietal wall and the gallbladder, and if we don\\'t free these adhesions, it won\\'t be possible to retract the liver because the gallbladder will be adherent to these adhesions, so we absolutely need to free them, but we will need the insertion of the next port.

01'59''

Liver freeing and retractionThis exposure is very important as otherwise we would not be able to lift the liver. The next trocar that will be inserted will be the 5mm trocar at the epigastric area. We cannot put the retractor at the usual level, due to the adipose tissue of this woman who has a BMI of 40. The retractor is always deployed under direct control. It will be placed below the liver. These little adhesions are under tension so it\\'s very easy to free them by application of very simple electricity, monopolar cautery set at 20 Watts. This type of hepatic adhesions are very common at the beginning of the procedure, that\\'s why the first instruments are always inserted under direct control; now we can change the position of the camera and put the camera at its original position. The first step is very standardized, it\\'s the mobilization of the liver, we don\\'t care about the gland, about the size and position of the gland. First, we have to mobilize the liver and to get a complete access to the adrenal area. The adrenal area is located below the right segment of the liver. So we have to completely free the adhesions of the liver until the right ligament is mobilized in order to have a complete access to this area. Progressive tension below the liver will allow to retract it. Here, we see the peritoneal reflection has to be opened but on the same hand, we have to open the triangular ligament and its attachment, and opening is performed until the triangular ligament joins the posterior layer of the peritoneal reflection, which is usually very well seen here, as long as the dissection is performed here, interestingly this is now facilitated in this patient thanks to his fat, because it gives you a nice plane. There is a risk otherwise at this level to have an injury to the diaphragm, that\\'s why it\\'s maybe beneficial here to a have an adipose patient. Again, the liver is gently mobilized, as we will need to have access to the posterior attachment of the gland. Here the gland is largely surrounded by fat.

05'00''

First landmark: vena cavaSo when the liver is free, the first landmark that we are going to look for will be the vena cava. Here we see that there are immediately some more vessels than usually, this is related to the inflammation of the pheochromocytoma. Now we will turn a bit the camera, change the orientation, with the objective to identify our landmarks. I will complete the freeing of some adhesions at the level of the gallbladder. We will see that now the orientation of everything is completely different, and we see the interest to have freed this adhesion close to the gallbladder, because the gallbladder has to stay far away from the operative field. I don\\'t want to do a cholecystectomy in this patient so I prefer to stay in the omentum. Here there are adhesions between the gallbladder and the duodenum. The patient is placed in a full lateral position, and thanks to this position, we don\\'t have to mobilize the duodenum really. Here I only free the type of adhesion we have seen previously. Now we like to work with little peanuts to attach the tissue, to retract the tissue, to really avoid any injury of anything. Now we can identify the landmarks, we have the gallbladder here, the second duodenum here, which is not impacted which means we will look for the vena cava here, in this area. We identify the color of the gland here but we never look directly for the gland. There is very little inflammation and the vena cava will be somewhere here, so the opening will be between the attachment of the duodenum and the vena cava as the vena cava is really the first landmark of dissection. Now the dissection will be performed very slowly and very progressively.

Here we identify probably the vena cava. A little bit change of the anatomy due to previous surgery, but really as you see the objective will be to make a freeing of each millimetre and taking care of all the little vessels. All the little vessels will be controlled by bipolar cautery when necessary. That is the anterior part of the vena cava. We work with a very low power of cautery, 20 Watts, to avoid diffusion of electricity.

08'12''

Minor bleedingIt\\'s a little vasa-vasorum usually surrounding these big veins, if it is something more we can put a stitch. This very little bleeder will be treated with compression as it is a millimetric one, probably there is no need for suturing; if there is any more bleeding, we will complete with a lateral stitch, but usually it can controlled without it. I will put some hemostatic device here. It is really a millimetric hole, but in fact in this patient, the central venous pressure is at 12, which means that even with a millimetric perforation, or tear of a micro-vein, it bleeds, so we will just keep compression.

09'07''

Lateral dissection of vena cavaWe leave this area for a while, and we go ahead with the dissection of the lateral part of the vena cava. Due to this previous adhesion we will use the 5mm Ligasure™, it\\'s a very effective device to free this fat adherent here. Dissection is performed downwards until the origin of the renal vein, which is the inferior landmark of dissection. All the tissue between the vena cava and the gland should be coagulated. We see there are a lot of little veins that can bleed here. Imaging has shown preoperatively that the disease is located on the side of the vena cava. Another critical area may be this one, because we know that there may be a direct drainage of the gland in a hepatic vein, in about 15% of cases, and this may also be at the origin of significant bleeding. We understand here the main interest of a totally bloodless operative field. We can come here that is the total posterior dissection area, and all the tissue at the level of the gland is bleeding. There are many little veins that I will control with Ligasure™ application. Very close adhesion here between the liver and the gland. All the people doing hepatic surgery know that during the dissection of the left lobe of the liver, there is always a risk of bleeding when mobilizing the adrenal gland and that is typically this area. We see that behind this there is only fat surrounding the adrenal gland, without any further risk, there are no vessels behind this. Dissection is completed until the diaphragm to be sure to avoid any remaining tissue. The more the gland is free upwards, the more we can pull it laterally also, and we increase progressively the dissection area. Now we come laterally to the vena cava. Again, the main interest here is that the patient is placed laterally, what is usually the posterior part of the vena cava, is here lateral, thanks to the position of the patient.

Here the vein that was cut previously with bipolar cautery can now be freed. We see that waiting is always a good solution for these very small bleeders. And now we keep it here, it can be used again. Now we will go slower and slower at this level, we know that there may be some veins, so a millimetric vein can be managed with very precise cautery. Here again we have a vein here, a very small one; we come back along the vena cava, we understand the importance of a very good view. Here there may be only fibrotic tissue, there may be a vein, so I always stay away from the vein. Again here we can free.

00'13''

Identification and control of main adrenal veinInterestingly here, we begin to guess where the adrenal vein will be here, there is still some oozing here, some tumor is here you see, the vein will be here, so we can begin the dissection from below in order to get access laterally to the gland and to have a length of 1cm approximately, that should allow us to apply clips very safely. So here you see that extremely small accessory veins are here. This can be also some veins, that is the main adrenal vein here. I cannot have a good access to the vein because there is adhesion here. So I will try to go on the right and the left, and again on the left and the right. It remains interesting because we increase the distance between the liver and the gland, we have a total posterior freeing. And again, the more we can lengthen the distance between the tumor and surrounding tissue, the easier it will be to control any bleeding.

So now, not enough distance to control the vein, we see that we have a very short vein in the vena cava, because the tumor is directly connected to the vein, my only solution again is to free the vena cava more, to have a longer part of the vena cava. Preoperative imaging did not show any thrombus, which is also very important, and which should have changed the approach significantly. We can do a progressive traction on the gland. We check with the anesthesiologist now changing the blood pressure, stable patient, 13 as arterial blood pressure. We begin to have an interesting dissection here. We clean the optic, which has a drop in the middle, change this instrument. We have a right-angled clamp; the objective is to try to go behind the vein, and look at what distance we have, and if we have a safe distance, to place a clip. The second advantage of this device is that it allows to perform a lateral clamping of the vena cava if necessary. We see that we have a correct length, posteriorly bleeding, which is very usual, we can then wait and then try to free the adhesion a bit here, to have a longer vein. Even if I have this very small oozing, I will wait until it stops, but I need to lengthen freeing of the gland, and I have seen thanks to my right-angled clamp that I have no other significant element behind. Oozing is coming from here, but now we can wait, and then we will come back to control the vein.

16'42''

Dissection of gland’s inferior poleSo here somewhere is the inferior pole of the gland, again we don\\'t look for the gland, our standard landmark will be the origin of the renal vein. So in less adipose patients, we can identify the upper pole of the kidney, which will be here I think, with palpation, so we open here the peritoneum. First, we open the peritoneal reflection line. This is performed ideally with the hook. That is the area of dissection, so we just open superficial adhesions, and here we see the avascular plane. It\\'s the kidney, the plane is a little bit over, at this place there is no risk, no vascular element; we don\\'t touch anything, just posteriorly here. The upper dissection is completed, the lateral dissection is completed. We just wait for the spontaneous hemostasis of a little vein to control the main adrenal vein. It remains a pheochromocytoma, so surrounding tissue can bleed very quickly.

18'16''

Posterior dissectionWe will go inferiorly to the gland, thanks to the landmark that we have identified. This freeing will be important to have the posterior dissection of the gland, and the access to the pedicle. We try to avoid blunt dissection, which could be effective, but usually associated with oozing. The gland is free, we see that we have dissection completed until the muscular layer, so posteriorly if even we have any malignant pheochromocytoma, it is an oncologic dissection with no remaining tissue of the adrenal gland in the adrenal area. Now the posterior dissection is achieved, we see that the remaining place is the inferior pole. The inferior pole is usually associated with an inferior artery and some nodes, so it can be also a little bit more hemorrhagic, the reason why I will go very progressively in this area, and perhaps not now, I don\\'t want to have a second bleeding place as long as I have not completed the first one.

19'47''

Clipping and division of main adrenal veinThere is no bleeding here for the moment and I check again, the presentation of the vein, where I will put the clip, now I see that I have a good length. Now open a little bit, no more bleeding, it will bleed when I take it out, yes it will. Take a 10mm clip applier with an 8mm clip length. The first clip is the clip placed on the vena cava, it\\'s probably one of the most difficult to place because I have to find the area, and then I push on the side of the vena cava to have a good and complete lateral control. One on the side of the tumor, it\\'s OK, so I will try the second one even if it\\'s not fully complete. Here we see very well that it overlaps the vein completely, so we can cut the vein now. First cut half of the vein. No bleeding. I can cut the vein totally, and now I have a good distance behind the vein, because everything was free before, making complete all this fatty tissue, with the Ligasure™ device, which probably includes the upper pole artery. That is the tumor here, but there is no more vascularization.

21'27''

Lateral-medial dissection of glandNow we have to complete the internal pole, which includes the medial artery. Inferior freeing of all surrounding tissue. In this area, there is certainly the medial artery. This is a retrocaval drainage though hemostasis should be perfect, because it will be very difficult to come back at this level. Usually, we try to avoid grasping the gland to avoid rupture of the capsule.

00'22''

Dissection of gland’s inferior edge Here we are in the fat, internal angle. Now we will make the inferior pole here, you see that the dissection plane comes alone, but we want really no blunt dissection so we go ahead with the Ligasure™ device. That is fat behind, now a tension in the tissue; again here we certainly have the inferior pole, and we know that the tumor is at the upper pole so there is no risk of rupture of the capsule. Dissection is then completed in the fat behind. This is the good safety margin between the tumor and the fat, no grasping. So the key points are first to perform a very gentle manipulation of all the elements in order to avoid disruption of the tissue, pheochromocytoma is always inflammatory tissue as we have seen. A lot of things can bleed. This will be taken out, but as long as we are here, we are now just controlling the dissection area to see if there is a need of complementary bipolar cautery or not. All the lymphatics and the little vessels behind the vena cava can bleed so to avoid postoperative hematoma, we are used to checking and controlling cautery clearly.

24'11''

Extraction of glandOnly 10mm ports so it\\'s very easy to insert a bag. Immediately I will take the hemostatic swab. The gland is placed into the bag. The pheochromocytoma is in the bag, which will be extracted through the 12mm port. We leave this, check that there is no bleeding, no injury, you see everything is clean, no injury of the liver, no bleeding in the operating area. No drain, no suction.

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